Enhanced Recovery after Surgery Programme - NHS … · 1 Enhanced Recovery after Surgery Programme...
Transcript of Enhanced Recovery after Surgery Programme - NHS … · 1 Enhanced Recovery after Surgery Programme...
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Enhanced Recovery after Surgery Programme
Trans - Hiatal and Ivor - Lewis Oesphagectomy Integrated Care Pathway
Age:
Consultant:
Pre Operative Assessment Outcome:
Suitable for Day of surgery admission (DOSA)? Y N
Day before Surgery Admission (DBSA) Y N Admit .........days pre-op.
Critical care bed required post-op?
Booked Yes □ No □
Y N Level 2 or 3
Is the patient allergic to latex? Y N If Yes theatre informed:
Date: Time:
Is the patient’s BMI > 40? Y N If Yes theatre informed:
Date: Time:
Does the patient need to be first on list? Y N
Is the patient suitable for carbohydrate loading Y N If No reason ……………
Time of last :
Time of last free fluids …………
Time of last clear fluids/’Pre-Op’ ………….
Assessing Nurse: Signature: Date:
Date of Admission:
Operation:
Date of surgery:
Predicted date of discharge
(PDD):
Actual date of
discharge:
Length of stay
Removed from pathway
Date: Reason
Addressograph
Unit no.: DoB:
Name:
Address:
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1. This Integrated Care Pathway (ICP) is a multidisciplinary document and replaces all other documentation to
form the patient’s sole record of care. It is intended as a guide to good practice and is evidence based. (NB
point
2. The ICP is not a rigid document and clinicians are free to use their own professional judgement as appropriate,
recording as a variance any alterations to the practice outlined, or any deviation from the expected plan of
treatment.
3. When using the pathway, sign yourself on below stating your discipline. Always use black ink
4. All sections should be fully completed. Please follow all instructions.
5. It is essential that all entries are signed and dated as indicated. Sign only for care that YOU have carried out or
outcomes that have been met.
6. When completing the pathway insert:
� Your initials if the outcome / plan has been met
� A X if it has not been met
� A 0 If the outcome / plan is not applicable to that patient
7. Any variation from the expected plan/ outcome of care: anything that happens that is not expected outcome /
plan is recorded as a VARIANCE.
8. In recording variances, please give as much information as possible
9. All variances must be recorded on the variance / multi-disciplinary notes sheet. Document the variance code
for the relevant action / outcome alongside the written detail of the variance
10. The Cardiff and Vale UHB generic risk assessment book must be used alongside this ICP to ensure that
patients undergo appropriate risk assessment during their stay
11. It may also be appropriate to use a nursing care plan as an adjunct to the pathway. Please make a record
below of the care plans in place and ensure each one is evaluated TDS in the multidisciplinary notes.
All patients Generic risk assessment book
Diabetic patients Diabetes core care plan
Relevant acute
pain team care
plans
Epidural care plan
PCA care plan
Intrathecal morphine care plan
12. If an outcome of care is not applicable to that patient write (0)
13. If the pathway is no longer suitable for a patient, discontinue the pathway, document why as a variance and
fill in the date in the table on page 1.
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SOCIAL ASSESSMENT
Patient lives with:
Are they fit and well? Yes � No
Are they coping at home at present? Yes � No �
Are there stairs / steps in the home? Yes � No �
Does the patient care for anyone? Yes � No �
If Yes who?
Does the patient have a carer? Yes � No �
If Yes who?
Would patient or family like to see a Social
Worker Yes � No � If yes, reason:
Is OT assessment required Yes � No �
Does the patient have complex discharge needs?
Yes � No �
Are patient and family happy with social
circumstances and to organise own support
on discharge?
Yes � No �
Are there any adaptations / rails in the home?
Yes � No �
Date: Nurse signature:
Patient details Patient Known as:
Home telephone: Mobile telephone:
Email address Marital status:
Occupation Religion
1st Language Translator required Yes � No �
First contact Second contact
Name: Name:
Relationship to patient: Relationship to patient:
Address:
Address:
Home telephone: Home telephone:
Work telephone: Work telephone:
Mobile telephone: Mobile telephone:
To be contacted:
In an emergency: Yes � No �
At night: Yes � No �
To be contacted:
In an emergency: Yes � No �
At night: Yes � No �
GP details
Telephone number:
Practice address:
If social work referral required / discharge is complex complete Unified Assessment forms
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Presenting Symptoms: (include dysphagia, vomiting, weight loss, anaemia, mass, appetite loss, pain, GI
bleed)
Pre-op chemotherapy? yes ☐☐☐☐ no ☐☐☐☐ regime regime regime regime ☐☐☐☐ date completeddate completeddate completeddate completed ☐☐☐☐
Pre-op chemoradiotherapy? yes ☐☐☐☐ no ☐☐☐☐ date completeddate completeddate completeddate completed ☐☐☐☐
Previous
anaesthetic problems:
Family history of anaesthetic problems:
Previous motion sickness or post-operative nausea/vomiting: yes ☐☐☐☐ no ☐☐☐☐
Pre-operative clerking
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Cardiovascular Y N Expand here:
MI □ □
Angina / Chest pain □ □
Hypertension □ □
AF / Arrhythmia □ □
Heart failure □ □
Stroke / TIA □ □
Previous cardiac surgery □ □
Coronary artery stents □ □
Pacemaker □ □
DVT / PE □ □
Palpitations / faints / syncope □ □
Rheumatic fever □ □
Peripheral vascular disease □ □
Respiratory
Asthma □ □
COPD / bronchitis / emphysema □ □
TB □ □
Sleep apnoea / snoring □ □
Cough □ □ Productive □ Haemoptysis □
Endocrine
Diabetes □ □ diet □ tablets □ insulin □
Thyroid disease □ □
Haematological
Excessive bleeding / bruising □ □
Anaemia / blood disorders □ □
Sickle cell disease □ □
GI/GU
Liver disease / jaundice / hepatitis □ □
Heartburn / acid reflux □ □
Hiatus hernia □ □
Stomach / duodenal ulcer □ □
Kidney / bladder problems □ □
Past medical history
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CNS
Epilepsy / fits □ □
Neurological disorder □ □
Anxiety / Depression □ □
Psychiatric Illness □ □
Other
Arthritis/joint problems □ □
LMP …………….. Could you be pregnant? Yes No
Inoculation risk □ □
Other □ □ Maximum walking distance on flat …………… (yards / metres)
□ bed bound □ wheelchair bed to chair □ 5m end of room
□ 25m end of ward □ 100m length of football pitch □ 400m
□ 2km 30min walk □ >2km normal pace, no exercise limitation ��
Walking limited by □ joint pain □ breathing □ chest pain □ leg pain
□ balance □ fatigue □ other
Do you get SOB walking up a flight of 12 stairs? Y N Do you get chest pain walking up a flight of 12 stairs? Y N Orthopnoea Y N (State no. of pillows ……..) PND Y N Peripheral Oedema Y N
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Abdomen
WEIGHT LOSS:
Weight pre illness:
Weight loss in KG:
Time frame of weight
loss:
Hand Signs:
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Neurological
Investigations ordered (*=essential)
□ FBC* Hb: Plat: WCC: MCV:
□ U&E* Na: K: Ur: Creat:
□ G+S*
□ LFT*
□ Coagulation screen
□ Blood Glucose
□ HbA1c
□ TFT
□ Sickle cell
□ Arterial blood gases
□ MSU
□ MRSA swabs
□ ECG
□ CXR
□ Echocardiogram
□ Pulmonary function tests
□ CPX
□ Other
* NB: Please document FBC, U+E results and any other abnormal results above
Possum-O
Calculate Possum-O on-line - http://www.riskprediction.org.uk/op-index.php
Score = ………………….
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Signature ………………… Date ……………..
Commence Drug chart
Prescribe the following, unless contraindicated for this patient
Complete thromboprophylaxis risk assessment Yes ☐
Enoxaparin (Clexane) Yes ☐ N/A ☐
� dose as per thromboprophylaxis risk assessment
� Commence at 1800 if admitted day before surgery (Do not give on morning of surgery)
Thromboembolism
Anti-embolism stockings (AES) Yes ☐ N/A ☐
Is bowel prep indicated and required Yes ☐ No ☐ Bowel Preparation
Refer to consultant instruction
Picolax Prescribed if indicated at management plan Yes ☐ N/A ☐
Omit any ACE inhibitors or Angiotensin II Receptor blockers on the morning
of surgery. Yes ☐ N/A ☐
Aspirin/Clopidogrel - stop 7days before surgery (discuss with anaesthetist)
Yes ☐ N/A ☐
Continue patients other usual medications (See anaesthetic guidelines on
‘Management of Perioperative Medicines’) Yes ☐ N/A ☐
Medications
Warfarin – discuss management with POAC anaesthetist Yes ☐ N/A ☐
Analgesia Paracetamol 1g qds (IV/oral) from post-op day 0 Yes ☐
Anti-emetics Cyclizine 50mg tds IV/oral Yes ☐ Ondansetron 4mg tds IV/oral Yes ☐
Antibiotics Co-Amoxiclav 1.2mgs IV on induction Yes ☐
Metronidazole 500mg IV on induction Yes ☐
Oxygen Oxygen therapy continually post-operation Yes ☐
Nutrition Carbohydrate loading: Refer to ward protocol Yes ☐ N/A ☐ document to be given 2-3 hours before surgery on drug chart � NB: Do not give within 4 hours of operation if previous gastric surgery or
severe reflux
Contra indications to NSAIDs Caution to NSAID use
Renal impairment Pregnancy / breast feeding
History of peptic ulceration Asthma
Hypersensitivity to NSAIDs CCF
Asthma hypersensitivity to aspirin Concurrent anti-coagulant therapy
Coagulopathy Hepatic impairment
Preoperative nursing assessment
Doctors name: Signature: Date:
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Risk assessments completed and documented in generic risk assessment book
Initials
Waterlow Pressure ulcer risk assessment tool
Malnutrition risk assessment (WAASP) Weight……....Kgs (actual not estimated)
Pat-e-bac risk assessment
Falls and bedrails Risk assessment
Thromboprophylaxis risk assessment (doctor to complete)
Unified Assessment: Not to be completed for simple discharges
Patient education record:
Relative/carer present: Yes ☐ No ☐ Relationship to patient:
Teaching provided. Date: Yes N/A Initials
Understanding of Enhanced Recovery Programme & patient’s role
Fasting instructions
Bowel prep
Pain control
Mobilisation post-op
Carbohydrate loading
Pre and post operative dietary advice
Nutritional supplements
Thromboprophylaxis therapy
Deep breathing, leg exercises and preventing pressure ulcers
Smoking cessation advice
Written information provided:
Enhanced recovery programme
Surgery
Anaesthesia/analgesia
Discharge plans discussed
Family/social support plans for discharge discussed
Patient contract signed
Patient Diary given
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Referrals
Y
Reason for
referral
Name/contact
referred to
Anaesthetist for notes review
Upper GI CNS
Dietician
Physiotherapist
Occupational Therapist
Acute pain team
Social services
Smoking cessation
Other
MRSA screen:
Full MRSA screen required if patient is being admitted from a nursing home or another hospital,
or if they are known to have had MRSA in the past:
MRSA screen sent: Yes ☐ No ☐ Not applicable ☐
Name of pre-assessment nurse:
Signature: Date
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Physiotherapy – Preoperative Check List
Yes No Reason
Pain relief, in relation to Physiotherapy
Attachments, in relation Physiotherapy
Suitable clothing and footwear
Getting in and out of bed
Early mobilisation
Generic exercises
Breathing exercises taught and practiced
Supported cough
Return to normal activities
Driving
Booklet provided
Scholes Score: High Low
At risk of PPC?
Chest assessment : complete for all patients with a high Scholes score, chronic chest disease or cough
HABAM Score: Balance Transfers Mobility
At risk of mobility problems?
Taking into account complete assessment findings - is the Patient for routine post- operative Physiotherapy review?
Sign: Date: Print:
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Nutrition and Dietetic - Preoperative Checklist
Yes No Reason
WAASP completed
MUST completed
SGA completed
Advised on carbohydrate loading
Food fortification advice
Advised on need for nutritional supplements x 3 day and explain different types available
Post operative dietary advice - early oral diet
Weight history and anthropometric assessment
Record of dietary intake
Diet sheet provided
Snacks and high protein options discussed
Any special dietary requirements?
Catering informed of special dietary requirement (as appropriate)
Nutritional requirements calculated Energy…………kcal Protein……….g
Malnutrition Risk Screening - WAASP
W A A S P Overall Risk of
Malnutrition
Malnutrition Universal Screening Tool - MUST
Step 1 Step 2 Step 3 Overall risk of Malnutrition
Sign: Date: Print:
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Anaesthetic /CPX Clinic Revised Cardiac Risk Index Score: Score 1 point for each variable:
High-risk surgery (includes any intraperitoneal, intrathoracic, or suprainguinal vascular procedures)
History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use
of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the
other criteria for ischemic heart disease is present).
History of heart failure
History of cerebrovascular disease
Diabetes mellitus requiring treatment with insulin
Preoperative serum creatinine >177 µmol/L
TOTAL
CPX test Y N
ASA status 1 2 3 4 5
Peri-operative medicines instructions:
Continue all medicines on day of surgery ☐ or Continue all meds except list below ☐
Drug chart amended re: above instructions Yes ☐ No ☐
Anaesthetist name & signature: Date:
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Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
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Pre-operative Admission Day. Date:……………
Doctor: pm night Variance Code
Record changes in health status since POA in multidisciplinary notes PDr1
Record changes in medicines since POA in multidisciplinary notes PDr2
Check consent form has been signed and white copy has been given to patient PDr3
X-rays and ECG available PDr4
Investigations completed and results available PDr5
FBC/U&E/LFT performed within 14 days? Yes ☐ No ☐
If no then repeat on admission Yes ☐ N/A ☐
PDr6
If patient on warfarin INR check Yes ☐ Anaesthetist informed if INR > 1.4 Yes ☐ PDr7
G+S sample sent (2nd G+S sample for electronic blood issue) PDr8
Prescription chart written PDr9
On admission:
Patient fully aware of planned surgery PT1
Patient orientated to ward [NB: access to nutritional supplements] PT2
Repeat observations. (T, P, R, BP, SpO2 + weight) POb
Enoxaparin given at 1800 hours PM1
If prescribed patient measured for Anti-embolic stockings and stockings provided PAes
Identity band in place, patient details confirmed PN1
Bowel preparation: Discussed with consultant / Registrar and prescribed if required – please make a record on variance sheet if required
PM3
Referrals: Referred to pain control nurse PNr1
Inform physiotherapist of admission PNr2
Inform dietician of admission PNr3
Referred to Social worker, OT and Discharge liaison if required
Please document these referrals on variance sheet PNr4
Nutrition
Normal diet and fluids – stop diet 6 hours pre theatre: Time diet to stop:
(Unless undergoing bowel preparation) ………… PNU1
Bowel preparation: Administered if required and as prescribed
Record weight (kg) Insert weight………..(KG) PNW
Recalculate Malnutrition risk assessment and record changes (WAASP) PNA
Encourage Ensure Plus x2 supplement drinks are given 1 ☐ 2 ☐ PNS
Insert initials if achieved, a x if
not achieved and 0 if not
applicable
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Carbohydrate loading: give 4 x 200ml ‘Pre-Op’ drinks evening before surgery
1 ☐ 2 ☐ 3 ☐ 4 ☐ NIGHT STAFF:NIGHT STAFF:NIGHT STAFF:NIGHT STAFF: please refer to operation day 0 re: administration of ‘Pre-Op’ drinks x 2 between 05.00 and 06.00. NB: Do not give if Diabetic or within 4 hours
of operation, previous gastric surgery or severe reflux PClam
pm night Variance Code
Patient Education
Importance of mobility post op and deep breathing and limb exercises PEm
Surgery / treatment plan PST
Importance of post op nutrition and early enteral feeding PN2
Patient’s and relatives’ roles in recovery process PER
Discharge arrangements PDis
Operation Day (day 0) Date:...................
Preoperative: Estimated time of surgery:
Yes Signature
Confirm G+S sample sent (2nd G+S sample for electronic blood issue) Doctor
No food for 6 hours prior to surgery
Carbohydrate loading (Pre-Op drinks) and clear fluids
(up to 2 hr pre-op) 1 ☐ 2 ☐ NB: Do not give within 4 hours of operation if previous gastric surgery or severe reflux
Theatre check list completed
Wearing AES (Anti-embolism stockings)
Patient’s usual medications given as prescribed
(omit ACE inhibitors or Angiotensin II Receptor blockers
on day of surgery)
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Operation Notes Date: Consultant: Surgeon 1: Surgeon 2: Surgeon 3: Surgeon 4: Anaesthetist: Scrub Nurse: Anaesthetic time started: Time into theatre: Operation time started: Time finished: Site of cancer: Operation title: Cancer treatment intent:
Blood loss:
HDU/ICU admission (please circle): Planned Unplanned
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Yes No Long-acting sedative premed avoided Seen in preop Anaesthetic Clinic CPX test performed DOSA Long-acting sedative pre-med avoided Carbohydrate loading taken 2-3hours preop Spinal Intrathecal Diamorphine Intrathecal Diamorphine with 0.5% heavy Bupivacaine TAP block Epidural Intraop Dexamethasone given as antiemetic Intraop Ondansetron given as antiemetic Bair Hugger Temp probe Warmed iv fluids Temp on leaving theatre Antibiotics prior to skin excision Cardiac Output Monitor used Volume (mls)
Total intraop crystalloid volume given Total intraop colloid volume given
Anaesthetic data (to be completed in theatre by anaesthetist
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Post op: Day 0 (Day of operation) Date:....................
Plan: Pain well controlled, IV fluids, oxygen and catheter in situ, sterile water via jejunostomy
PM Night Variance
Code
Admitted to critical care 0ICU
Observations and EWS score completed ½ hrly for 2 hrs, 1 hrly for 2 hrs and then
2 hrly. Actions taken as per EWS chart: document actions on variance sheet 0Ob
Deep breathing promoted, patient able to deep breath and cough. 0Db
Sputum clear 0Sp
Oxygen in place as prescribed and oxygen saturations maintained above 97% 0O2
Fluid balance chart completed hourly 0Fb
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr) Follow
GIFTASUP recommendations
0ivi
Central line care as per care bundle - site healthy 0Clb
Hourly catheter measurements (maintain 0.3 ml/kg/hour averaged over 4 hours)
Expected 1hourly output =…………….ml/hr Expected 4 hourly rate: …………..
0Uc
Strictly Nil By Mouth 0Nbm
Patient checked for signs of paralytic ileus – ie: nausea / vomiting, increased pain,
pulse >100 and/or abdominal distension – nil present
0Pi
NG tube insitu on free drainage only – no fresh blood noted
Do NOT aspirate or repass a NGtube without consultant direction
0Ng
Jejunostomy insitu - Administer sterile water at 10ml/hr for 12 hours using an enteral feeding pump
Sterile water should commence at 6pm post operative unless contra-indicated.
0Jejw
Pain assessed with each set of observations at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
0Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
0Ep
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
0Slr
VIP score completed for all venflons insitu 0Vip
Wound observed when observations recorded no bleeding / signs of infection 0W
Insert initials if achieved,
a x if not achieved and
0 if not applicable
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Chest drain monitored and oscillation noted with each set of observations, note
colour and volume. Number of chest drains insitu …………………..
0Cd
Record output via Chest drain BD 0Cdor
PM Night Variance
Code
Abdominal drains checked, drainage measured and recorded before 12MN, blood
and haemoserous fluid draining volume is less than 200 mls
Number of drains insitu: …………………….
0Ad
Patient assisted to reposition 2 hourly by day / ………….. hourly by night 0Rep
Pressure areas checked all blanching with no discolouration / broken areas 0Pr
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken areas present) 0Aes
Waterlow, Pat-e-bac, falls and WAASP risk assessments recalculated post op 0Ra
Doctor: Blood tests (FBC, U & E) taken 0Dr1
Doctor: Blood tests (FBC, U & E) results reviewed and normal 0Dr2
Doctor: Review drug chart, change medications to IV whilst NBM 0Dr3
Physiotherapy – respiratory assessment/treatment 0Ph1
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Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
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Post op: Day 1 (Day of operation) Date:....................
Plan: Lung re-inflated, observations stable, pain well controlled, sat out of bed, aim to achieve 40mls /hr of enteral feed by end of day 1.
am pm night Variance Code
Trans-hiatal oesophagectomy – transferred to ward C2
1C2
Ivor Lewis oesophagectomy – transferred to HDU
1HDU
Observations and EWS score recorded 2 hourly. Actions taken as
per EWS chart: document actions required on variance sheet
1Ob
Deep breathing promoted, patient able to deep breathe and cough. 1Db
Sputum clear 1Sp
Oxygen therapy maintained and oxygen sats > 97%) 1O2
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
1Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
1Ep
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
1Slr
Flatus passed 1Fl
Faeces passed 1Bo
Strictly Nil By Mouth 1Nbm
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTISUP recommendations
1ivi
Jejunostomy insitu - If tolerating10ml/hr sterile water for 12 hours commence feed.
1Jejw
Commence Osmolite at 20ml/hr unless contra-indicated, increase
rate by 10mls per every 6 hours until a max of 80mls/h is reached.
Flush 6hrly with 30mls of sterile water.
1Jejf
Clean jejunostomy site daily with normal saline, check integrity of
sutures. (If suture not intact secure jejunostomy and inform team)
1Jejc
Weight recorded ………Kgs 1Wt
VIP score completed for all venflons insitu 1Vip
Fluid balance chart completed hourly 1Fb
Monitor urine output 1 hourly (maintain 0.3 ml/kg/hr) 1Uc
NG tube insitu and reviewed by consultant, haemoserous fluid / bile draining
1Ng
Nausea assessed 2 hourly and actions taken as per protocol 1Na
Insert initials if achieved,
a x if not achieved and
0 if not applicable
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am pm night Variance Code
Patient checked for signs of gastric dilatation / paralytic ileus – ie:
nausea / vomiting, increased pain, pulse >100 and/or abdominal
distension – nil present
1Pi
Hygiene needs met 1Hy
Wound observed no bleeding / signs of infection noted 1W
Abdominal drains monitored and reviewed by Registrar / Consultant 1Ad
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
1Cd
Record output via Chest drain BD 1Cdor
Apical / anterior drains in situ - fluid level oscillating – no bile or
over 100 mls of blood
1Cdos
Out of bed x 2 times in total and record length of time sat out
1 ☐ ……………… 2 ☐ ………………
1Sc
Walks (Tick once each walk achieved and estimate distance)
1 ☐ ……………………..
1Wa
Pressure areas checked all blanching with no discolouration / broken areas
1Pr
Patient assisted to reposition 2 hourly by day / ………….. hourly by night
1Rep
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 1Aes
AES completely removed once in 24 hours for maximum of 30 mins for hygiene care and skin inspection
1Aesr
Doctor: Blood tests (FBC, U & E) taken 1Dr1
Doctor: Blood tests (FBC, U & E) results reviewed and normal 1DR2
Doctor: Review drug chart, change medications to IV whilst NBM 1Dr3
Doctor: Book Gastrografin swallow if required for Day 5 or 7 (if day 5 is a weekend)
1Dr4
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
1Dr5
Physiotherapy – respiratory assessment/treatment 1Ph1
Physiotherapy – mobility assessment 1Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed
1Ph5
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Postoperative Morbidity Survey (POMS) Day 1 post-op
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C
in the last 24hr.
Renal Presence of oliguria <500 ml/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
* If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
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Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
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Plan: Aim to achieve 80mls /hr of enteral feed by end of day 2, fluid
balanced achieved, pain well controlled, sitting out and mobilising with
assistance
AM PM Night Variance
code
Ivor Lewis Oesophagectomy transferred to ward C2 2C2
Observations and EWS chart score recorded 2hourly whilst PCA and
epidural insitu, Actions taken as per EWS chart: document all actions on
variance sheet
2Ob
Deep breathing promoted, patient able to deep breath and cough. 2Db
Sputum clear 2Sp
Oxygen saturations > 97% on prescribed oxygen 2O2
Fluid balance chart completed 1 hourly 2Fb
VIP score completed for all venflons in situ – Score 0 2Vip
Strictly Nil By Mouth 2Nbm
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTAISUP recommendations
2ivi
Continue Osmolite via jejunostomy unless contra-indicated, increase rate by 10mls per every 6 hours until a max of 80mls/h is reached. Flush 6hrly with 30mls of sterile water.
2Jejf
Clean jejunostomy site daily with normal saline, check integrity of
sutures. (If suture not intact secure jejunostomy and inform team)
2Jejc
Monitor urine output 1 hourly
(maintain minimum of 0.3 ml/kg/hour averaged over 4 hours)
2Uc
Weight recorded ………Kgs 2Wt
If weight gain>3kgs request surgical review 2Wtg
NG tube insitu and reviewed by consultant, haemoserous fluid / bile draining. Free Drainage Only
2Ng
Nausea assessed 2 hourly and actions taken as per protocol 2Na
Flatus passed 2Fl
Faeces passed. 2Bo
Patient checked for paralytic ileus - ie. Nausea/vomiting, increased
pain, pulse> 100 and/or abdominal distension, nil present
2Pi
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
2Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
2Ep
Insert initials if achieved, a x if
unachieved and O if not
applicable
Post op day 2 Date:
32
AM PM Night Variance
code
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
2Slr
Wound observed, no bleeding or signs of infection noted 2W
Abdominal drains monitored and reviewed by Registrar / Consultant 2Ad
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
2Cdos
Record output via Chest drain BD 2Cdor
Hygiene needs met. 2Hy Out of bed x 2 times in total and record length of time sat out
1 ☐ ……………… 2 ☐ ……………… 2Sc
Walks x 2 (Tick once each walk achieved and estimate distance)
1 ☐ …………………….. 2 ☐ ………………….. 2Wa
Foot exercises whilst in bed / whilst sat out in chair 2Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 2Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 2Aesr
Pressure areas checked all blanching with no discolouration / broken areas
2Pr
Patient reminded to reposition 2 hourly by day and ……… by night 2Rep
Risk assessment scores reassessed if any change in condition 2Ra
Remind patient of ERAS programme requirements 2Pe
Doctor: Blood tests (FBC, U & E) taken 2Dr1
Doctor: (FBC, U & E) results reviewed and normal 2Dr2
Doctor: Review drug chart, change medications to IV whilst NBM 2Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
2Dr5
Physiotherapy: respiratory assessment/treatment 2Ph1
Physiotherapy: Mobility assessment 2Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 2Ph5
33
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
34
Postoperative Morbidity Survey (POMS) Day 2 post-op
Morbidity type Criteria Tick if
present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in
the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
* If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
35
Post op day 3 Date: ………………..
Plan: Tolerating feed via jejunostomy, IV fluid requirements reduced,
pain well controlled, sitting out and mobilising with assistance
AM PM Night Variance
code
Observations and EWS chart score recorded 2hourly whilst PCA and
epidural insitu, Actions taken as per EWS chart: document all actions on
variance sheet
3Ob
Deep breathing promoted, patient able to deep breath and cough. 3Db
Sputum clear 3Sp
Oxygen saturations > 97% on prescribed oxygen 3O2
Fluid balance chart completed 1 hourly 3Fb
VIP score completed for all venflons in situ – Score 0 3Vip
Strictly Nil By Mouth 3Nbm
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTASUP recommendations
3ivi
Continue target feeding regimen via jejunosotmy as devised by dietician unless contra-indicated
Flush 6hrly with 30mls of sterile water.
3Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
3Jejc
Monitor urine output 1 hourly
(maintain minimum of 0.3 ml/kg/hour averaged over 4 hours)
3Uo
Weight recorded ………Kgs 3Wt
If weight gain>3kgs request surgical review 3Wtg
NG tube insitu and reviewed by consultant, haemoserous fluid / bile draining. Free Drainage Only
3Ng
Flatus passed 3Fl
Faeces passed. 3Bo
Patient checked for paralytic ileus-ie. Nausea/vomiting, increased
pain, pulse> 100 and/or abdominal distension, nil present
3Pi
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
3Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
3Ep
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
3Slr
Insert initials if achieved, a x if
unachieved and O if not
applicable
36
AM PM Night Variance
code
Wound observed, no bleeding or signs of infection noted 3W
Abdominal drains reviewed by team and removed if less than 50 mls
drained in previous 24 hours
3Ad
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
3Cdos
Record output via Chest drain BD, 3Cdor
Hygiene needs met. 3Hy
Out of bed x 3 times in total and record length of time sat out
1 ☐ ……………… 2 ☐ ……………… 3 ☐ ……………… 3Sc
Walks x 2 (Tick once each walk achieved and estimate distance)
1 ☐ …………………….. 2 ☐ ………………….. 3Wa
Foot exercises whilst in bed / whilst sat out in chair 3Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 3Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 3Aesr
Pressure areas checked all blanching with no discolouration / broken areas
3Pr
Patient reminded to reposition 2 hourly by day and ……… by night 3Rep
Risk assessment scores reassessed if any change in condition 3Ra
Remind patient of ERAS programme requirements 3Pe
Doctor: Blood tests (FBC, U & E) taken 3Dr1
Doctor: (FBC, U & E) results reviewed and normal 3Dr2
Doctor: Review drug chart, change medications to IV whilst NBM 3Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
3Dr5
Physiotherapy: respiratory assessment/treatment 3Ph1
Physiotherapy: Mobility assessment 3Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 3Ph5
37
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
38
Postoperative Morbidity Survey (POMS) Day 3 post-op
If no score above then please state reason why patient is still in hospital
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in
the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal
Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular
Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological
Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
* If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
39
Plan: Tolerating feed via jejunostomy, IV fluid requirements reduced,
pain well controlled, sitting out and mobilising with assistance
AM PM Night Variance
code
Observations and EWS chart score recorded 2hourly whilst PCA and
epidural insitu, Actions taken as per EWS chart: document all actions on
variance sheet
4Ob
Deep breathing promoted, patient able to deep breath and cough. 4Db
Sputum clear 4Sp
Oxygen saturations > 97% on prescribed oxygen 4O2
Fluid balance chart completed 1 hourly 4Fb
VIP score completed for all venflons in situ – Score 0 4Vip
Strictly Nil By Mouth 4Nbm
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTASUP recommendations
4ivi
Continue target feeding regimen via jejunosotmy as devised by dietician unless contra-indicated
Flush 6hrly with 30mls of sterile water.
4Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
4Jejc
Monitor urine output 1 hourly
(maintain minimum of 0.3 ml/kg/hour averaged over 4 hours)
4Uo
Weight recorded ………Kgs 4Wt
If weight gain>3kgs request surgical review 4Wtg
NG tube insitu and reviewed by consultant, haemoserous fluid / bile
draining. Free Drainage Only
4Ng
Flatus passed 4Fl
Faeces passed. 4Bo
Patient checked for paralytic ileus-ie. Nausea/vomiting, increased
pain, pulse> 100 and/or abdominal distension, nil present
4Pi
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
4Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
4Ep
Insert initials if achieved, a x if unachieved and O if not applicable
Post op day 4 Date:
40
AM PM Night
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
4Slr
Wound observed, no bleeding or signs of infection noted 4W
Abdominal drains reviewed by team and removed if less than 50 mls
drained in previous 24 hours
4Ad
Remove abdominal drain if instructed and documented in patients
notes.
4Adr
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
4Cdos
Record output via Chest drain BD, 4Cdor
Hygiene needs met. 4Hy
Out of bed x 4 times in total and record length of time sat out
1 ☐ ………… 2 ☐ …………… 3 ☐ …………… 4 ☐ ……………
4Sc
Walks x 3 (Tick once each walk achieved and estimate distance)
1 ☐ ……………. 2 ☐ ………………… 3 ☐ ……………… 4Wa
Foot exercises whilst in bed / whilst sat out in chair 4Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 4Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 4Aesr
Pressure areas checked all blanching with no discolouration / broken areas
4Pr
Patient reminded to reposition 2 hourly by day and ……… by night 4Rep
Risk assessment scores reassessed if any change in condition 4Ra
Remind patient of ERAS programme requirements 4Pe
Doctor: Blood tests (FBC, U & E) taken 4Dr1
Doctor: (FBC, U & E) results reviewed and normal 4Dr2
Doctor: Review drug chart, change medications to IV whilst NBM 4Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
4Dr5
Physiotherapy: respiratory assessment/treatment 4Ph1
Physiotherapy: Mobility assessment 4Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 4Ph5
41
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
42
Postoperative Morbidity Survey (POMS) Day 4 postop
Morbidity type Criteria
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last
24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
Date: Doctor’s signature: Bleep no:
Date: Doctor’s signature: Bleep no:
43
Plan: DAY 5 AM PM Night Variance
code
Observations and EWS chart score recorded 2hourly whilst PCA and
epidural insitu, 4 hourly once discontinued. Actions taken as per EWS
chart: document all actions on variance sheet
5Ob
Deep breathing promoted, patient able to deep breath and cough. 5Db
Sputum clear 5Sp
Oxygen saturations > 97% on prescribed oxygen 5O2
Fluid balance chart completed 1 hourly 5Fb
VIP score completed for all venflons in situ – Score 0 5Vip
Strictly Nil By Mouth 5Nbm
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTASUP recommendations
5ivi
Continue target feeding regimen via jejunosotmy as devised by dietician unless contra-indicated
Flush 6hrly with 30mls of sterile water.
5Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
5Jejc
Monitor urine output 1 hourly
(maintain minimum of 0.3 ml/kg/hour averaged over 4 hours)
5Uo
Weight recorded ………Kgs 5Wt
If weight gain>3kgs request surgical review 5Wtg
NG tube insitu and reviewed by consultant, haemoserous fluid / bile draining. Free Drainage Only
5Ng
Flatus passed 5Fl
Faeces passed. 5Bo
Patient checked for paralytic ileus-ie. Nausea/vomiting, increased
pain, pulse> 100 and/or abdominal distension, nil present
5Pi
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
5Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
5Ep
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
5Slr
Wound observed, no bleeding or signs of infection noted 5W
Abdominal drains reviewed by team and removed if less than 50 mls
drained in previous 24 hours
5Ad
Post op day 5 Date: Insert initials if achieved, a x if
unachieved and O if not
applicable
44
AM PM Night Variance
code
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
Cdos
Record output via Chest drain BD, Cdor
Gastrograffin swallow to confirm integrity of anastamosis
(to be carried out on day 6 / 7 if day 5 is a weekend day)
5Gs5
Following successful swallow - Commence sips of water on
Consultant’s instruction and clearly documented in patients
notes.
5Of
Following successful swallow - Remove NG tube and chest drain on
Consultant’s instruction and clearly documented in patient’s
notes.
5Ngr
Hygiene needs met. 5Hy
Out of bed x 4 times in total and record length of time sat out
1 ☐ ………… 2 ☐ …………… 3 ☐ …………… 4 ☐ ……………
5Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
5Wa
Foot exercises whilst in bed / whilst sat out in chair 5Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 5Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 5Aesr
Pressure areas checked all blanching with no discolouration / broken areas
5Pr
Patient reminded to reposition 2 hourly by day and ……… by night 58Rep
Risk assessment scores reassessed if any change in condition 5Ra
Remind patient of ERAS programme requirements 5Pe
Doctor: Blood tests (FBC, U & E) taken 5Dr1
Doctor: (FBC, U & E) results reviewed and normal 5Dr2
Doctor: Review drug chart, change medications to appropriate route for administration
5Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
5Dr5
Physiotherapy: respiratory assessment/treatment 5Ph1
Physiotherapy: Mobility assessment 5Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 5Ph5
45
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
46
Postoperative Morbidity Survey (POMS) Day 5 postop
Morbidity type Criteria
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
• If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
47
Plan: AM PM Night Variance code
Observations and EWS chart score recorded 2hourly whilst PCA and
epidural insitu, 4 hourly once discontinued. Actions taken as per EWS
chart: document all actions on variance sheet
6Ob
Deep breathing promoted, patient able to deep breath and cough. 6Db
Sputum clear 6Sp
Oxygen saturations > 97% on prescribed oxygen 6O2
Fluid balance chart completed 1 hourly 6Fb
VIP score completed for all venflons in situ – Score 0 6Vip
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTASUP recommendations
6ivi
Continue target feeding regimen via jejunosotmy as devised by dietician unless contra-indicated
Flush 6hrly with 30mls of sterile water.
6Jejf
Clean jejunostomy site daily with normal saline, check integrity of
sutures. (If suture not intact secure jejunostomy and inform team)
6Jejc
Monitor urine output 6Uo
Weight recorded ………Kgs 6Wt
If weight gain>3kgs request surgical review 6Wtg
NG tube insitu and reviewed by consultant, haemoserous fluid / bile
draining. Free Drainage Only
6Ng
Nausea assessed 2 hourly and anti-emetics given as per protocol if
required – nausea well controlled
6Na
Continue oral fluids as instructed and documented on variance
sheet (if swallow is successful).
6Of
Flatus passed 6Fl
Faeces passed. 6Bo
Patient checked for paralytic ileus-ie. Nausea/vomiting, increased
pain, pulse> 100 and/or abdominal distension, nil present
6Pi
Consider discontinuing epidural /PCA and commencing IV / oral analgesia. (Document if epidural / PCA discontinued on variance sheet)
6Epr
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
6Pa
Wound observed, no bleeding or signs of infection noted
6W
AM PM Night Variance
code
Insert initials if achieved, a x
if unachieved and O if not applicable
Post op day 6 Date:
48
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
6Ep
Straight leg raises checked 4 hourly for 24hrs post removal of epidural – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
6Slr
Gastrograffin swallow to confirm integrity of anastamosis ( if not
carried out day 5, to be carried out on day 7 if day 6 is a weekend
day) Commence sips of water on Consultant’s instruction and
clearly documented in patients notes.
6Gs6
Remove NG tube on Consultant’s instruction and clearly
documented in patient’s notes.
6Ngr
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume. Remove if instructed and
documented in patients notes
6Cdos
Record output via Chest drain BD, 6Cdor
Hygiene needs met. 6Hy
Out of bed x 5 times in total and record length of time sat out
1 ☐ ………… 2 ☐ ………… 3 ☐ …………… 4 ☐ …………… 5 ☐ …………
6Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
6Wa
Foot exercises whilst in bed / whilst sat out in chair 6Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 6Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 6Aesr
Pressure areas checked all blanching with no discolouration / broken areas
6Pr
Patient reminded to reposition 2 hourly by day and ……… by night 6Rep
Risk assessment scores reassessed if any change in condition 6Ra
Remind patient of ERAS programme requirements 6Pe
Doctor: Blood tests (FBC, U & E) taken 6Dr1
Doctor: (FBC, U & E) results reviewed and normal 6Dr2
Doctor: Review drug chart, change medications to appropriate route for administration
Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
6Dr5
Physiotherapy: respiratory assessment/treatment 6Ph1
Physiotherapy: Mobility assessment 6Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 6Ph5
49
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
50
Postoperative Morbidity Survey (POMS) Day 6 post op
Morbidity type Criteria
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
* If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
51
Plan: Day 7 AM PM Night Variance
code
Observations and EWS chart score recorded 4 hourly. Actions taken
as per EWS chart: document all actions on variance sheet
7Ob
Deep breathing promoted, patient able to deep breath and cough. 7Db
Sputum clear 7Sp
Oxygen saturations > 97% on prescribed oxygen 7O2
Fluid balance chart completed 1 hourly 7Fb
VIP score completed for all venflons in situ – Score 0 7Vip
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTASUP recommendations or Consider discontinuing IV
fluids
7ivi
Continue target feeding regimen via jejunosotmy as devised by dietician unless contra-indicated
Flush 6hrly with 30mls of sterile water.
7Jejf
Clean jejunostomy site daily with normal saline, check integrity of
sutures. (If suture not intact secure jejunostomy and inform team)
7Jejc
Gastrograffin swallow to confirm integrity of anastamosis (to be
carried out on day 7 if day 5 is a weekend day)
Commence sips of water on Consultant’s instruction and clearly
documented in patients notes.
7Gs7
Remove NG tube on Consultant’s instruction and clearly
documented in patient’s notes.
7Ngr
Continue oral fluids and diet as instructed and documented on
variance sheet.
7Of
Maintain food chart (if diet has been commenced) 7Fc
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume. Remove if instructed and
documented in patients notes
7Cdoc
Record output via Chest drain BD, 7Cdor
Catheter removed □ Monitor urine output on fluid balance chart 7Uo
Weight recorded ………Kgs 7Wt
If weight gain>3kgs request surgical review 7Wtg
Faeces passed. 7Bo
Continue balanced IV analgesia. Pain assessed with each set of
observations at rest and deep breathing - actions taken as per
protocol and relevant care plans
7Pa
Post op day 7 Date: Insert initials if achieved, a x if
unachieved and O if not
applicable
52
AM PM Night Variance
code
Epidural site checked 8 hourly, note for oozing redness and swelling.
Actions taken as per protocol and relevant care plans (PCA / epidural)
7Ep
Straight leg raises 4 hourly 7Slr
Nausea assessed 2 hourly and anti-emetics given as per protocol if
required – nausea well controlled
7Na
Wound observed, no bleeding or signs of infection noted 7W
Enable hygiene to be maintained at a high standard whilst promoting
independence
7Hy
Out of bed x 6 times in total and record length of time sat out
1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………
5 ☐ ………… 6 ☐ …………
7Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
7Wa
Foot exercises whilst in bed / whilst sat out in chair 7Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 7Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 7Aesr
Pressure areas checked all blanching with no discolouration / broken areas
7Pr
Patient reminded to reposition 2 hourly by day and ……… by night 7Rep
Risk assessment scores reassessed if any change in condition 7Ra
Remind patient of ERAS programme requirements 7Pe
Doctor: Blood tests (FBC, U & E) taken 7Dr1
Doctor: (FBC, U & E) results reviewed and normal 7Dr2
Doctor: Review drug chart, change medications to appropriate route for administration
7Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
7Dr5
Physiotherapy: respiratory assessment/treatment 7Ph1
Physiotherapy: Mobility assessment 7Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 7Ph5
53
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
54
Postoperative Morbidity Survey (POMS) Day 7 postop
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
• If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
55
Plan: Day 8 AM PM Night Variance
code
Observations and EWS chart score 4 hourly once discontinued.
Actions taken as per EWS chart: document all actions on variance sheet
8Ob
Deep breathing promoted, patient able to deep breath and cough. 8Db
Sputum clear 8Sp
Oxygen saturations > 94%-97% on room air or prescribed oxygen 8O2
Fluid balance chart completed 1 hourly 8Fb
VIP score completed for all venflons in situ – Score 0 8Vip
Consider changing to overnight feeding, follow feeding regime. 8Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
8Jejc
Continue oral fluids and diet as instructed and documented on
variance sheet.
8Of
Maintain food chart 8Fc
Monitor urine output 8Uo
Weight recorded ………Kgs 8wt
If weight gain>3kgs request surgical review 8Wtg
Faeces passed. 8Bo
Continue balanced IV analgesia. Pain assessed with each set of
observations at rest and deep breathing - actions taken as per
protocol and relevant care plans
8Pa
Epidural site checked 8 hourly, note for oozing redness and swelling.
Straight leg raises 4 hourly
Actions taken as per protocol and relevant care plans (PCA / epidural)
8Ep
Nausea assessed 2 hourly and anti-emetics given as per protocol if
required – nausea well controlled
8Na
Wound observed, no bleeding or signs of infection noted 8W
Enable hygiene to be maintained at a high standard whilst promoting
independence
8Hy
Out of bed x 8 times in total and record length of time sat out
1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………
5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………
8sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
8Wa
Foot exercises whilst in bed / whilst sat out in chair 8Fe
Post op day 8 Date: Insert initials if achieved, a x if
unachieved and O if not
applicable
56
AM PM Night Variance
code
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 8Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 8Aesr
Pressure areas checked all blanching with no discolouration / broken areas
8Pr
Patient reminded to reposition 2 hourly by day and ……… by night 8Rep
Risk assessment scores reassessed if any change in condition 8Ra
Remind patient of ERAS programme requirements 8Pe
Doctor: Blood tests (FBC, U & E) taken 8Dr1
Doctor: (FBC, U & E) results reviewed and normal 8Dr2
Doctor: Review drug chart, change medications to appropriate route for administration
8Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
8Dr5
Physiotherapy: respiratory assessment/treatment 8Ph1
Physiotherapy: Mobility assessment 8PH2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 8Ph5
57
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Please
record all
variances or
Details, reason and action taken
Signature and
bleep number
58
Postoperative Morbidity Survey (POMS) Day 8 postop
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
59
Plan: Day 9 AM PM Night Variance
code
Observations and EWS chart score 8 hourly. Actions taken as per
EWS chart: document all actions on variance sheet
9Ob
Deep breathing promoted, patient able to deep breath and cough. 9Db
Sputum clear 9Sp
Oxygen saturations > 94%-97% on room air or prescribed oxygen 9O2
Fluid balance chart completed 1 hourly 9Fb
VIP score completed for all venflons in situ – Score 0 9Vip
Continue overnight jejunostomy feeding, follow feeding regime. 9Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
9Jejc
Continue oral fluids and diet as instructed and documented on
variance sheet.
9Of
Maintain food chart 9Fc
Monitor urine output 9Uo
Weight recorded ………Kgs 9Wt
If weight gain>3kgs request surgical review 9Wtg
Faeces passed. 9Bo
Consider oral analgesia (see Appendix) and continue pain
assessment with each set of observations at rest and deep breathing.
9Pa
Epidural site checked 8 hourly, note for oozing redness and swelling.
Actions taken as per protocol and relevant care plans (PCA / epidural)
9Ep
Nausea assessed with each set of observations and anti-emetics
given as per protocol if required – nausea well controlled
9Na
Wound observed, no bleeding or signs of infection noted 9W
Enable hygiene to be maintained at a high standard whilst promoting
independence
9Hy
Out of bed x 8 times in total and record length of time sat out
1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………
5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………
9Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
9Wa
Insert initials if achieved, a x if unachieved and O if not applicable
Post op day 9 Date: …………..
60
Foot exercises whilst in bed / whilst sat out in chair 9Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 9Aes
AM PM Night Variance
code
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 9Aesr
Pressure areas checked all blanching with no discolouration / broken areas
9Pr
Patient reminded to reposition 2 hourly by day and ……… by night 9Rep
Risk assessment scores reassessed if any change in condition 9Ra
Remind patient of ERAS programme requirements 9Pe
Doctor: Blood tests (FBC, U & E) taken 9Dr1
Doctor: (FBC, U & E) results reviewed and normal 9Dr2
Physiotherapy: respiratory assessment/treatment 9Ph1
Physiotherapy: Mobility assessment 9Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 9Ph5
61
AM PM Night Variance
code
Observations and EWS chart score 4 hourly once discontinued.
Actions taken as per EWS chart: document all actions on variance sheet
8O
Deep breathing promoted, patient able to deep breath and cough. 8N1
Sputum clear 8N2
Oxygen saturations > 97% on prescribed oxygen 8N3
Fluid balance chart completed 1 hourly 8N4
VIP score completed for all venflons in situ – Score 0
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTISUP recommendations
Jejunostomy insitu – follow feeding regime
Continue oral fluids as documented in patient’s notes.
Monitor urine output 8N6RU
Weight recorded ………Kgs 8NW
If weight gain>3kgs request surgical review 8NWG
Flatus passed 8NF
Faeces passed. 8NS
Patient checked for gastric dilatation/paralytic ileus-ie.
Nausea/vomiting, increased pain, pulse> 100 and/or abdominal
distension, nil present
8N16
Continue balanced IV analgesia. Pain assessed with each set of
observations at rest and deep breathing - actions taken as per
protocol and relevant care plans
Epidural site checked 8 hourly, note for oozing redness and swelling.
Straight leg raises 4 hourly
Actions taken as per protocol and relevant care plans (PCA / epidural)
Nausea assessed 2 hourly and anti-emetics given as per protocol if
required – nausea well controlled
8N10
Wound observed, no bleeding or signs of infection noted 8NWO
Abdominal drains monitored and reviewed by Registrar / Consultant
Remove abdominal drain if instructed and documented in patients
notes.
AM PM Night Variance
code
Enable hygiene to be maintained at a high standard whilst promoting
independence
8NH
Out of bed 8 hours in total (Tick once each hour achieved) 8MO1
AM PM Night Variance
code
62
Postoperative Morbidity Survey (POMS) Day 9 post-op
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
* If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
63
Plan: Day 10 AM PM Night Variance
code
Observations and EWS chart score 8 hourly. Actions taken as per
EWS chart: document all actions on variance sheet
10Ob
Deep breathing promoted, patient able to deep breath and cough. 10Db
Sputum clear 10Sp
Oxygen saturations > 94%-97% on room air 10O2
Fluid balance chart completed 1 hourly 10Fb
VIP score completed for all venflons in situ – Score 0 10Vip
Continue overnight feeding, follow feeding regime. 10Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
10Jejc
Continue oral fluids and diet as instructed and documented on
variance sheet.
10Of
Maintain food chart 10Fc
Monitor urine output 10Uo
Weight recorded ………Kgs 10Wt
If weight gain>3kgs request surgical review 10Wtg
Faeces passed. 10Bo
Oral analgesia (see Appendix) and continue pain assessment with
each set of observations at rest and deep breathing.
10Pa
Nausea assessed with each set of observations and anti-emetics
given as per protocol if required – nausea well controlled
10Na
Wound observed, no bleeding or signs of infection noted 10W
Enable hygiene to be maintained at a high standard whilst promoting
independence
10Hy
Out of bed x 8 times in total and record length of time sat out
1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………
5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………
10Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
10Wa
Foot exercises whilst in bed / whilst sat out in chair 10Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 10Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 10Aesr
Post op day 10 Date: ………….. Insert initials if achieved, a x
if unachieved and O if not applicable
64
AM PM Night Variance
code
Pressure areas checked all blanching with no discolouration / broken areas
10Pr
Risk assessment scores reassessed if any change in condition 10Ra
Remind patient of ERAS programme requirements 10Pe
Doctor: Blood tests (FBC, U & E) taken 10Dr1
Doctor: (FBC, U & E) results reviewed and normal 10Dr2
Physiotherapy: respiratory assessment/treatment 10Ph1
Physiotherapy: Mobility and stair assessment as required 10Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 10Ph5
65
AM PM Night Variance
code
Observations and EWS chart score 4 hourly once discontinued.
Actions taken as per EWS chart: document all actions on variance sheet
8O
Deep breathing promoted, patient able to deep breath and cough. 8N1
Sputum clear 8N2
Oxygen saturations > 97% on prescribed oxygen 8N3
Fluid balance chart completed 1 hourly 8N4
VIP score completed for all venflons in situ – Score 0
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTISUP recommendations
Jejunostomy insitu – follow feeding regime
Continue oral fluids as documented in patient’s notes.
Monitor urine output 8N6RU
Weight recorded ………Kgs 8NW
If weight gain>3kgs request surgical review 8NWG
Flatus passed 8NF
Faeces passed. 8NS
Patient checked for gastric dilatation/paralytic ileus-ie.
Nausea/vomiting, increased pain, pulse> 100 and/or abdominal
distension, nil present
8N16
Continue balanced IV analgesia. Pain assessed with each set of
observations at rest and deep breathing - actions taken as per
protocol and relevant care plans
Epidural site checked 8 hourly, note for oozing redness and swelling.
Straight leg raises 4 hourly
Actions taken as per protocol and relevant care plans (PCA / epidural)
Nausea assessed 2 hourly and anti-emetics given as per protocol if
required – nausea well controlled
8N10
Wound observed, no bleeding or signs of infection noted 8NWO
Abdominal drains monitored and reviewed by Registrar / Consultant
Remove abdominal drain if instructed and documented in patients
notes.
AM PM Night Variance
code
Enable hygiene to be maintained at a high standard whilst promoting
independence
8NH
Out of bed 8 hours in total (Tick once each hour achieved) 8MO1
AM PM Night Variance
code
66
Postoperative Morbidity Survey (POMS) Day 10 post-op
Morbidity type
Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
• If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
67
Plan: Day 11
AM PM Night Variance
code
Observations and EWS chart score 6 hourly. Actions taken as per
EWS chart: document all actions on variance sheet
11Ob
Deep breathing promoted, patient able to deep breath and cough. 11Db
Sputum clear 11Sp
Oxygen saturations > 94%-97% on room air 11O2
Fluid balance chart completed 1 hourly 11Fb
VIP score completed for all venflons in situ – Score 0 11Vip
Continue overnight feeding, follow feeding regime. 11Jejf
Clean jejunostomy site daily with normal saline, check integrity of
sutures. (If suture not intact secure jejunostomy and inform team)
11Jejc
Continue oral fluids and diet as instructed and documented on
variance sheet.
11Of
Maintain food chart 11Fc
Monitor urine output 11Uo
Weight recorded ………Kgs 11Wt
If weight gain>3kgs request surgical review 11Wtg
Faeces passed. 11Bo
Oral analgesia (see Appendix) and continue pain assessment with
each set of observations at rest and deep breathing.
11Pa
Nausea assessed with each set of observations and anti-emetics
given as per protocol if required – nausea well controlled
11Na
Wound observed, no bleeding or signs of infection noted 11W
Enable hygiene to be maintained at a high standard whilst promoting
independence
11Hy
Out of bed x 8 times in total and record length of time sat out
1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………
5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………
11Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
11Wa
Foot exercises whilst in bed / whilst sat out in chair 11Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 11Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 11Aesr
Post op day 11 Date: ………….. Insert initials if achieved, a x
if unachieved and O if not applicable
68
AM PM Night Variance
code
Pressure areas checked all blanching with no discolouration / broken areas
11Pr
Patient reminded to reposition 2 hourly by day and ……… by night 11Rep
Risk assessment scores reassessed if any change in condition 11Ra
Remind patient of ERAS programme requirements 11Pe
Doctor: Blood tests (FBC, U & E) taken 11Dr1
Doctor: (FBC, U & E) results reviewed and normal 11Dr2
Physiotherapy: respiratory assessment/treatment 11Ph1
Physiotherapy: Mobility and stair assessment as required 11Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed 11Ph5
69
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Please
record all
variances or
Details, reason and action taken
Signature and
bleep number
70
Postoperative Morbidity Survey (POMS) Day 11 post-op
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
• If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
71
Plan: Day 12 AM PM Night Variance
code
Observations and EWS chart score 8 hourly. Actions taken as per
EWS chart: document all actions on variance sheet
12Ob
Deep breathing promoted, patient able to deep breath and cough. 12Db
Sputum clear 12Sp
Oxygen saturations > 94%-97% on room air 12O2
Fluid balance chart completed 1 hourly 12Fb
VIP score completed for all venflons in situ – Score 0 12Vip
Continue overnight feeding, follow feeding regime. 12Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
12Jejc
Continue oral fluids and diet as instructed and documented on
variance sheet.
12Of
Maintain food chart 12Fc
Monitor urine output 12Uo
Weight recorded ………Kgs 12Wt
If weight gain>3kgs request surgical review 12Wtg
Faeces passed. 12Bo
Oral analgesia (see Appendix) and continue pain assessment with
each set of observations at rest and deep breathing.
12Pa
Nausea assessed with each set of observations and anti-emetics
given as per protocol if required – nausea well controlled
12Na
Wound observed, no bleeding or signs of infection noted 12W
Enable hygiene to be maintained at a high standard whilst promoting
independence
12Hy
Out of bed x 8 times in total and record length of time sat out
1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………
5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………
11Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
11Wa
Foot exercises whilst in bed / whilst sat out in chair 12Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 12Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 12Aesr
Post op day 12 Date: ………….. Insert initials if achieved, a x
if unachieved and O if not applicable
72
AM PM Night Variance
code
Pressure areas checked all blanching with no discolouration / broken areas
12Pr
Patient reminded to reposition 2 hourly by day and ……… by night 12Rep
Risk assessment scores reassessed if any change in condition 12Ra
Remind patient of ERAS programme requirements 12Pe
Doctor: Blood tests (FBC, U & E) taken 12Dr1
Doctor: (FBC, U & E) results reviewed and normal 12Dr2
Physiotherapy: respiratory assessment/treatment 12Ph1
Physiotherapy: Mobility and stair assessment as required 12Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed
12Ph5
Confirm discharge plans 12Disc
Discharge information and teaching given regarding care of and
flushing of jejunosotomy.
12DisE
73
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Please
record all
variances or
Details, reason and action taken
Signature and
bleep number
74
Postoperative Morbidity Survey (POMS) Day 12 post-op
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
• If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
75
Plan: Day 13 AM PM Night Variance
code
Observations and EWS chart score 8 hourly. Actions taken as per
EWS chart: document all actions on variance sheet
13Ob
Deep breathing promoted, patient able to deep breath and cough. 13Db
Sputum clear 13Sp
Oxygen saturations > 94%-97% on room air 13O2
Fluid balance chart completed 1 hourly 13Fb
VIP score completed for all venflons in situ – Score 0 13Vip
Continue overnight feeding, follow feeding regime. 13Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
13Jejc
Continue oral fluids and diet as instructed and documented on
variance sheet.
13Of
Maintain food chart 13Fc
Monitor urine output 13Uo
Weight recorded ………Kgs 13Wt
If weight gain>3kgs request surgical review 13Wtg
Faeces passed. 13Bo
Oral analgesia (see Appendix) and continue pain assessment with
each set of observations at rest and deep breathing.
13Pa
Nausea assessed with each set of observations and anti-emetics
given as per protocol if required – nausea well controlled
13Na
Wound observed, no bleeding or signs of infection noted 13W
Enable hygiene to be maintained at a high standard whilst promoting
independence
13Hy
Out of bed x 8 times in total and record length of time sat out
1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………
5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………
13Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
13Wa
Foot exercises whilst in bed / whilst sat out in chair 13Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 13Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 13Aesr
Pressure areas checked all blanching with no discolouration / broken areas
13Pr
Patient reminded to reposition 2 hourly by day and ……… by night
13Rep
Post op day 13 Date: ………….. Insert initials if achieved, a x
if unachieved and O if not applicable
76
AM PM Night Variance
code
Risk assessment scores reassessed if any change in condition 13Ra
Remind patient of ERAS programme requirements 13Pe
Doctor: Blood tests (FBC, U & E) taken 13Dr1
Doctor: (FBC, U & E) results reviewed and normal 13Dr2
Physiotherapy: respiratory assessment/treatment 13Ph1
Physiotherapy: Mobility and stair assessment as required 13Ph2
Physiotherapy: Discharge advice given if appropriate 13Ph4
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed
13Ph5
Confirm discharge for following day with patient and relatives 13Disc
Discharge plan fully completed (TTH, District Nurse) 13Disp
Discharge information and teaching given regarding care of
jejunosotomy. Ensure correct amount of syringes are available for
daily flush (single use) until OPA
13DisE
77
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Please
record all
variances or
Details, reason and action taken
Signature and
bleep number
78
Postoperative Morbidity Survey (POMS) Day 13 post-op
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation+6).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
• If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
79
Plan: Day 14 AM PM Night Variance
code
Observations and EWS chart score 8 hourly. Actions taken as per
EWS chart: document all actions on variance sheet
14Ob
Deep breathing promoted, patient able to deep breath and cough. 14Db
Sputum clear 14Sp
Oxygen saturations > 94%-97% on room air 14O2
Fluid balance chart completed 1 hourly 14Fb
VIP score completed for all venflons in situ – Score 0 14Vip
Discontinue feeds via jejunosotmy 14Jejf
Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)
14Jejc
Continue oral fluids and diet as instructed and documented on
variance sheet.
14Of
Maintain food chart 14Fc
Monitor urine output 14Uo
Weight recorded ………Kgs 14Wt
If weight gain>3kgs request surgical review 14Wtg
Faeces passed. 14Bo
Oral analgesia (see Appendix) and continue pain assessment with
each set of observations at rest and deep breathing.
14Pa
Nausea assessed with each set of observations and anti-emetics
given as per protocol if required – nausea well controlled
14Na
Wound observed, no bleeding or signs of infection noted 14W
Enable hygiene to be maintained at a high standard whilst promoting
independence
14Hy
Out of bed x 8 times in total and record length of time sat out
1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………
5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………
14Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
14Wa
Foot exercises whilst in bed / whilst sat out in chair 14Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 14Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 14Aesr
Pressure areas checked all blanching with no discolouration / broken areas
14Pr
Patient reminded to reposition 2 hourly by day and ……… by night 14Rep
Insert initials if achieved, a x if unachieved and O if not applicable
Post op day 14 Date: …………..
80
AM PM Night Variance
code
Risk assessment scores reassessed if any change in condition 14Ra
Remind patient of ERAS programme requirements 14Pe
Doctor: Blood tests (FBC, U & E) taken 14Dr1
Doctor: (FBC, U & E) results reviewed and normal 14Dr2
Physiotherapy: respiratory assessment/treatment 14Ph1
Physiotherapy: Mobility and stair assessment as required 14Ph2
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed
14PH5
Physiotherapy: Discharge advice given if appropriate 14Ph4
Confirm discharge for today with patient and relatives 14Disc
Discharge plan fully completed (TTH, District Nurse) 14Disp
Discharge information and teaching given regarding care of
jejunosotomy. Ensure correct amount of syringes are available for
daily flush (single use) until OPA
14DisE
Discharged 14Dis
81
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Please
record all
variances or
Details, reason and action taken
Signature and
bleep number
82
Postoperative Morbidity Survey (POMS) Day 14 post-op
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last 24hr.
Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
* If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
83
Start completing from day 1 of pathway
Date
Signature
Written
Dispensed by pharmacy
Explained to patient
Green card completed and explained to the patient
TTH
(NB Ibuprofen for 7 days post
op only)
GP letter
Letter completed
DISTRICT
NURSES Referral phoned out
Supply of products ready for discharge STOMA CARE
Follow up visit arranged: Date: Time:
OPA Cardiff ☐ Glamorgan ☐ Gwent ☐
Follow up phone
call
Follow up phone call arranged: Date :
WARDCONTACT Patient given ward contact number
OT Equipment required for discharge in place
PHYSIO Discharge agreed
Patients own arranged TRANSPORT
Hospital transport booked: Date: Time:
Referral made Hospital
discharge
service Date of discharge confirmed:
Date and time of first visit:
Discharge discussed with Home manager / Matron
Date of discharge confirmed with home
DISCHARGE TO
NURSING /
RESIDENTIAL
HOME Transfer letter completed
Discharge needs discussed with social worker
Social worker informed of actual discharge date
SOCIAL:
Package of care Date & time care package will start
DISCHARGE LEAFLET
Given to patient
Patient Diary Completed and put in notes
Addressograph
Discharge plan
Predicted date of discharge: Actual date of discharge:
84
Medically fit for discharge: Postop day: ……… Actual discharge: Postop day: ………
Hospital Length of Stay (= discharge date minus admission date) = ………. Preop days in hospital:……….
Complications Tick if
present
Acute myocardial infarction — at least two of:
• New onset or worsening of ischaemic symptoms (eg, chest pain, SOB) lasting > 20 min;
• Changes on the ECG consistent with ischaemia, including:
acute ST elevation followed by the appearance of Q waves or loss of R waves
new left bundle branch block
new persistent T wave inversion for at least 24 hours
new ST segment depression which persists for at least 24 hours
• A raised troponin level
Cardiac arrest — documented sudden cessation of cardiac output maintaining effective circulation
Reintubation
Acute pulmonary oedema — respiratory compromise with CXR showing extravascular fluid in lung tissues and alveoli
Pulmonary embolus — high probability of embolism on V/Q scan or pulmonary angiogram
DVT
Stroke — confirmed by CT scan, and clinical symptoms such as paralysis, weakness or speech difficulties, first documented after operation
Sepsis (systemic inflammatory response syndrome) — new finding of at least two of:
temperature, > 38.3°C, or < 36°C
white cell count, > 12x109/L
respiratory rate, > 20 breaths/min
heart rate, > 90 beats/min or
a positive result of a blood culture alone
Wound infection — purulent discharge or redness, or serous discharge and positive result of culture or having antibiotic treatment
Unplanned return to operating room — related to the surgery (eg, surgical bleeding)
Acute renal impairment — increase in serum creatinine level > 20% of preoperative value, or admission to ICU for renal replacement therapy
Unplanned admission — to ICU, CCU or HDU
Death within 30 days
Anastomotic leak
Ileus
Outcomes Record if any complication below is present during hospital stay from day 8 post op onwards.
Record the post op day that the complication occurs
85
Possum-O
Calculate Possum-O on-line - http://www.riskprediction.org.uk/op-index.php
Score = ………………….
Signature ………………… Date ……………..
86
Analgesia Appendix
Pain assessment
Pain must be assessed at rest, on movement and deep breathing using the terms none, mild, moderate or
severe (0-3). Pain should be assessed at least two hourly although in the initial postoperative period or if there
is a pain related problem more frequently.
Analgesia
Epidural analgesia with 2micrograms fentanyl/0.1% bupivacaine
Or
5micrograms fentanyl/0.1% bupivacaine
Or
0.1% bupivacaine only
With
Regular intravenous paracetamol
Intravenous PCA with regular paracetamol + NSAID (if not contraindicated)
Once epidural or PCA have been discontinued:
Intravenous step down analgesia day 7-9
Continue regular intravenous paracetamol
Regular intravenous tramadol 50-100mgs
S/C morphine hourly as required (algorithm)
Oral step down analgesia day 9 >
Continue regular intravenous paracetamol
Regular oral tramadol 50-100mgs
Oramorph hourly as required (algorithm)
Anti emetics
1st line Cyclizine 50 mgs as required 8 hourly intravenously
2nd line Ondansetron 4mgs as required 8 hourly intravenously
3rd line Prochloperazine 3-6 mgs twice daily as required via buccal mucosa
87
. Postoperative fluid management:
• Hartmann’s 1.5L over 24 hrs (=62.5 mls/hr)
• Oral intake 800mls on day of surgery.
• IVI down on post op day 1
• Oral intake 2000mls from day 1 (includes 3 nutritional supplement drinks)
• Aim for mean BP ≥60mmHg.
• If poor urine output or hypotension requiring iv fluids, use 250ml boluses of colloid.
• Patients with epidural analgesia may require more postoperative fluids than other
anaesthetic/analgesic techniques due to the vasodilatory effects of the epidural
• Acceptance of a lower average urine output (0.3 mls/kg/hr averaged over 4
hours)in the first 24-48hrs post-operatively helps to avoid fluid overload with no
adverse effect on the patient – as long as other parameters are normal and patient is
euvolaemic with no renal impairment. In the absence of complications, oliguria
occurring soon after operation is usually a normal physiological response to surgery.
• Oliguria soon after surgery does not necessarily reflect hypovolaemia and should be
evaluated in the context of the patient’s volume status. The key question is whether or
not the oliguric patient has significant intravascular hypovolaemia which needs
treatment. Clinical signs reflecting intravascular volume include capillary refill, jugular
(central) venous pressure, and the trend in pulse and blood pressure. Urine output
should be interpreted in the light of these clinical signs, bearing in mind the normal
short term physiological effects of surgery on urine output.
88•
Nursing responsibilities on admission for Oesophagectomy:
• Malnutrition Risk Assessment (WAASP) completed and patient weighed
• Encourage normal diet and supplements (unless undergoing bowel prep)
• Check prescription of Pre-Op as per carbohydrate loading protocol
Day 1 - 2 (Post-operative):
• If tolerates 10ml/hr sterile water for 12 hours commence feed
• Commence Osmolite at 20ml/hr unless contra-indicated
• Increase rate by 10ml every 6 hours
• Continue to increase rate by 10ml every 6 hours until rate of 80ml/hr achieved
• Feed over 24 hours and flush with 30ml of sterile water every 6 hours
• Target Jejunostomy feeding rates: o End of Day 1 – 40ml/hr o End of day 2 – 80ml/hr
• The final rate of feeding will be determined by the Dietitian in conjunction with the surgical/medical team
Day 0 (Operative Day) – Post Operative:
• Administer sterile water at 10ml/hr for 12 hours using an enteral feeding pump
• Sterile water should commence at 6pm post operative unless contra-indicated
• If contra-indicated the reason for not commencing sterile water should be clearly documented in the patients medical notes
Day before surgery:
• No bowel prep (unless for colonic interposition)
• Eat and drink normal diet
• Ensure Plus B.D.
• Pre-Op 200ml x 4 the evening before surgery
Day 0 - Operative Day:
• No food for 6 hours prior to surgery
• Clear fluids up to 2 hours prior to surgery
• Pre-Op 200ml x 2 up to 2 hours prior to surgery
• NBM 2 hours prior to surgery
Oesophagectomy and insertion of 9fr Freka feeding Jejunostomy
Day 3 - 7
• Continue target feeding regimen as devised by dietitian unless contra-indicated
• The reason for any variance form the target regimen should be clearly documented in the medical notes
Day 7 - 10:
• Swallow test and progress onto oral diet
• Change to overnight feeding
• Dietitian to advise on building up diet and reducing or stopping Jejunostomy feeding
Day 10 - 14:
• Dietitian to assess oral diet and consider stopping enteral feeding by Day 14
• If the patient requires HETF this would have been anticipated prior to and throughout their admission and all training would have been put in place
• Post discharge dietetic advice provided and follow up in UGI clinic at next OPA